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Complaint Administration Unit

Health Care Facility Complaint Form (Unlicensed)

If you think a health care facility may have violated the law relating to your care, or the care of someone you know, please provide as much detail as possible in the boxes below. When completing the "narrative" portion of the form, please include full names of patients/residents, and staff involved. If you know the diagnoses and type of insurance the patient/resident has, please include that information. When describing your concern, please include dates of when events happened. Incomplete information may result in our inability to take action. Please understand not all concerns may be actual violations of the law. In general, incidents older than twelve months do not result in an on-site inspection, though the information is retained in our file. After we have reviewed your information, we will send you an e-mail response explaining the disposition of your complaint.

* Indicates a required field.

Complaint Information
 

To verify that the facility is regulated by our Agency, or to view previous inspection reports, visit www.floridahealthfinder.gov

 
 
 
 
ex: Medicare, Medicaid, Private, Uninsured
   

This field does not allow more than 4000 characters. You may upload an attachment if necessary.

     
Please mark all that apply.

Complainant's Identifying Information (Optional)
 
 
 
 
ex: Internet search, Friend, AHCA Website

Thank you for sending us this information. If we determine we have legal authority to do a complaint inspection related to your concerns, we will do so. At that point, a surveyor (inspector) will review the laws that apply to your case, review the written information at the facility, observe care of current patients/residents, and conduct interviews with others receiving care, and staff providing care. The surveyor will determine if the facility is violating any law at the time of the inspection. You will receive notification with the results of the complaint inspection,if we have your contact information.

If you wish to print your completed form, please do so now, using your browser button. There will not be another opportunity to print this form.